Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of metoprolol despite specific physician-ordered parameters to hold the medication. The resident, who had diagnoses including dementia and hypertension, had an order for metoprolol extended release 25 mg daily, with instructions to hold the medication if the pulse was less than 60 or if the systolic blood pressure (SBP) was less than 130. Review of the Medication Administration Record for March 2025 showed that the medication was administered on six occasions when the resident's SBP was below the ordered threshold, and in one instance, the heart rate was also below the specified parameter. The DON confirmed that staff are expected to follow medication order parameters, and the surveyor verified that the medication was given contrary to these instructions.